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1.
Artigo em Inglês | MEDLINE | ID: mdl-31914788

RESUMO

Transgender women are 49 times more likely to become HIV positive than all adults worldwide. Data were unavailable for trans women's sexual and mental health in the Middle East and North Africa until 2015-2016, when HIV prevalence (10%) and suicide attempt (46%) rates were established in Lebanon. Because of the lack of evidence-based interventions for this marginalized group, the purpose of this study was to pilot test an adapted intervention, "Baynetna," to assess preliminary impact on mental and sexual health. Using the gender affirmative model and community connectedness and social cohesion constructs, we pilot tested Baynetna among sixteen trans women, who attended 6 weekly 3-h trans-facilitated group-delivered sessions in Beirut with post-test assessments at 1, 3, and 6 months. Each participant acted as her own control; we used paired t-tests to assess changes at follow-up to evaluate potential differences in outcomes. Positive directionality in intervention impact on gender affirmation satisfaction, community connectedness, and social cohesion was demonstrated. An increase in HIV testing proportion between 6 months before and after enrollment was achieved. Higher social cohesion was associated with less suicidal thoughts (p = .05). There was a significant (p = .019) relationship between more community connectedness and lower depression scores. War event exposure was associated with higher anxiety (p = .02; p = .004). Those who reported never having had a sexually transmitted infection had higher gender affirmation satisfaction scores (7.5, 95% confidence interval: 1.4-13.6) (p = .019). Increases in community connectedness, social cohesion, and gender affirmation satisfaction scores confirm Baynetna's proposed mechanisms of impact. Proportional HIV testing increases demonstrate prevention objectives' progress. The significant results contribute to confidence in Baynetna's mechanisms of action and support the hypothesis that the Gender Affirmation model is applicable to the Lebanese context. We have shown for the first time that the adapted intervention, and its constructs, are applicable in this context outside the United States.

2.
Circulation ; 140(20): 1639-1646, 2019 Nov 12.
Artigo em Inglês | MEDLINE | ID: mdl-31564126

RESUMO

BACKGROUND: Studies of patients with cardiovascular implantable electronic devices show a relationship between atrial fibrillation (AF) duration and stroke risk, although the interaction with CHA2DS2-VASc score is poorly defined. The objective of this study is to evaluate rates of stroke and systemic embolism (SSE) in patients with cardiovascular implantable electronic devices as a function of both CHA2DS2-VASc score and AF duration. METHODS: Data from the Optum electronic health record deidentified database (2007-2017) were linked to the Medtronic CareLink database of cardiovascular implantable electronic devices capable of continuous AF monitoring. An index date was assigned as the later of either 6 months after device implantation or 1 year after electronic health record data availability. CHA2DS2-VASc score was assessed using electronic health record data before the index date. Maximum daily AF burden (no AF, 6 minutes-23.5 hours, and >23.5 hours) was assessed over the 6 months before the index date. SSE rates were computed after the index date. RESULTS: Among 21 768 nonanticoagulated patients with cardiovascular implantable electronic devices (age, 68.6±12.7 years; 63% male), both increasing AF duration (P<0.001) and increasing CHA2DS2-VASc score (P<0.001) were significantly associated with annualized risk of SSE. SSE rates were low in patients with a CHA2DS2-VASc score of 0 to 1 regardless of device-detected AF duration. However, stroke risk crossed an actionable threshold defined as >1%/y in patients with a CHA2DS2-VASc score of 2 with >23.5 hours of AF, those with a CHA2DS2-VASc score of 3 to 4 with >6 minutes of AF, and patients with a CHA2DS2-VASc score ≥5 even with no AF. CONCLUSIONS: There is an interaction between AF duration and CHA2DS2-VASc score that can further risk-stratify patients with AF for SSE and may be useful in guiding anticoagulation therapy.

3.
iScience ; 19: 545-558, 2019 Sep 27.
Artigo em Inglês | MEDLINE | ID: mdl-31470363

RESUMO

The Growth Advantage in Stationary Phase (GASP) phenomenon, described in bacteria, reflects the genetic adaptation of bacteria to stress, including starvation, for a long time. Unlike in stationary phase where no cell division occurs, GASP harbors active cell division, concurrent with genetic adaptation. Here we show that GASP occurs also in eukaryotes. Two strains of Saccharomyces cerevisiae (Sc404 and Sc424) have been isolated from 2-year-old sealed bottles of beer. These strains presented advantage in survival and growth over the parent during stress. The differences between the strains are irreversible and therefore genetic in origin rather than epigenetic. Direct competition assays show that Sc404 and Sc424 outcompete the parent in direct competition. DNA sequencing shows changes of the genome: the TOR complexes are mutated, and DNA repair gene mutations confer a mutator phenotype. The differences between the strains are reflected in a difference in taste between beers brewed from them.

4.
Artigo em Inglês | MEDLINE | ID: mdl-31327104

RESUMO

PURPOSE: Cryoballoon ablation (CBA) is an effective technique for pulmonary vein isolation (PVI). To date, there are no risk models to predict very late recurrence of atrial fibrillation (VLRAF) after CBA. METHODS: Retrospective analysis of a single-center database was performed. Inclusion criteria included PVI using CBA for atrial fibrillation (AF) without additional ablation targets, follow-up > 365 days, and no recurrent AF between 90 and 365 days after procedure. The primary endpoint was recurrent AF > 30 s > 12 months post-CBA. A risk model was created using clinical variables. RESULTS: Of 674 CBA performed from 2011 to 2016, 300 patients (200 male, 62.0 ± 9.9 years) met inclusion criteria. Of these, 159 (53.0%) patients had paroxysmal AF. Patients had an average of 9.5 ± 2.7 cryoballoon freezes, and no patients required additional radiofrequency ablation lesion sets. Over a follow-up of 995 ± 490 days, 77/300 (25.7%) patients exhibited VLRAF. Univariate and multivariate analyses demonstrated that Structural heart disease (1 point), Coronary artery disease (3 points), left Atrial diameter > 43 mm (1 point), Left bundle branch block (3 points), Early return of AF (4 points), and non-paroxysmal AF (3 points) were risk factors for VLRAF. Combining these variables into a risk model, SCALE-CryoAF, (min 0; max 15) predicted VLRAF with an area under the curve of 0.73. CONCLUSION: SCALE-CryoAF is the first risk model to specifically predict first recurrence of AF beyond 1 year, VLRAF, after CBA. Model discrimination demonstrates that SCALE-CryoAF predicts VLRAF after CBA significantly better than other risk models for AF recurrence.

5.
Clin Case Rep ; 7(7): 1309-1311, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31360473

RESUMO

In patients who have had a prior subcutaneous ICD implanted, a sternotomy can be safely performed without the need for replacement of the ICD. Appropriate tools and closure technique during reimplantation are essential for this to be a possibility.

6.
Circulation ; 139(23): 2639-2641, 2019 Jun 04.
Artigo em Inglês | MEDLINE | ID: mdl-31158000
7.
Ann Epidemiol ; 35: 29-34, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31171443

RESUMO

PURPOSE: Given the adverse impacts of enforcement-based approaches toward sex work on female sex workers' (FSWs') health, safety, and well-being, we explored the prevalence and correlates of recent incarceration among FSWs in Iran. METHODS: From January to August 2015, we recruited FSWs from 21 harm reduction facilities and 152 FSWs from street venues in 13 major cities across Iran. Correlates of recent (i.e., last year) incarceration were assessed through an exploratory multivariable logistic regression model. RESULTS: A total of 90 of 1326 (6.8%) FSWs reported a recent incarceration; primary reasons for incarceration were drug-related (n = 48/90; 52.9%). Having a recent incarceration was significantly and positively associated with history of illicit drug use/injection (adjusted odds ratio [aOR] = 3.22, 95% confidence interval [CI]: 1.67, 6.19), rape in last year (aOR = 2.67, 95% CI: 1.65, 4.31), unstable housing (aOR = 2.28, 95% CI: 1.16, 4.91), and working in brothels (aOR = 2.22, 95% CI: 1.18, 4.16). CONCLUSIONS: In sum, recent incarceration was significantly associated with history of drug use and sociostructural vulnerabilities. Taken together, these data suggest the potential health impacts of the integration of programs to mitigate substance use, sexual violence, and living conditions into comprehensive services for FSWs in Iran.

8.
mBio ; 10(2)2019 04 30.
Artigo em Inglês | MEDLINE | ID: mdl-31040238

RESUMO

Ancient fermented food has been studied based on recipes, residue analysis, and ancient-DNA techniques and reconstructed using modern domesticated yeast. Here, we present a novel approach based on our hypothesis that enriched yeast populations in fermented beverages could have become the dominant species in storage vessels and their descendants could be isolated and studied today. We developed a pipeline of yeast isolation from clay vessels and screened for yeast cells in beverage-related and non-beverage-related ancient vessels and sediments from several archaeological sites. We found that yeast cells could be successfully isolated specifically from clay containers of fermented beverages. The findings that genotypically the isolated yeasts are similar to those found in traditional African beverages and phenotypically they grow similar to modern beer-producing yeast strongly suggest that they are descendants of the original fermenting yeast. These results demonstrate that modern microorganisms can serve as a new tool in bio-archaeology research.IMPORTANCE So far, most of the study of ancient organisms has been based mainly on the analysis of ancient DNA. Here we show that it is possible to isolate and study microorganisms-yeast in this case-from ancient pottery vessels used for fermentation. We demonstrate that it is highly likely that these cells are descendants of the original yeast strains that participated in the fermentation process and were absorbed into the clay matrix of the pottery vessels. Moreover, we characterized the isolated yeast strains, their genomes, and the beer they produced. These results open new and exciting avenues in the study of domesticated microorganisms and contribute significantly to the fields of bio- and experimental archaeology that aim to reconstruct ancient artifacts and products.


Assuntos
Arqueologia/métodos , Fósseis/microbiologia , Sedimentos Geológicos/microbiologia , Técnicas Microbiológicas/métodos , Leveduras/isolamento & purificação , Genótipo
9.
AIDS Educ Prev ; 31(3): 246-258, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31145003

RESUMO

Transgender women are among the most at risk of populations for HIV infection and transmission globally. Feasible and acceptable intervention strategies that are culturally and contextually appropriate are urgently needed to address the burden of disease worldwide. The first study to address the unique health needs of transgender women in the Middle East and North Africa, this mixed-methods pilot (N = 16) demonstrated high levels of feasibility and acceptability among adult transgender women in Lebanon as measured quantitatively and qualitatively in the domains of: time allotment, venue, group dynamics, facilitation, content, and retention. The intervention, adapted from an existing trans-facilitated group support intervention, addresses the sexual and mental health of transgender women with mixed HIV status. Next steps should include scale-up, randomization, and testing to determine larger-scale feasibility, acceptability, and efficacy for mitigating sexual and mental health risk and promoting community connectedness and social cohesion.


Assuntos
Terapia Comportamental , Infecções por HIV/prevenção & controle , Aceitação pelo Paciente de Cuidados de Saúde , Psicoterapia de Grupo , Pessoas Transgênero/psicologia , Adulto , Estudos de Viabilidade , Feminino , Infecções por HIV/psicologia , Serviços de Saúde , Humanos , Líbano , Masculino , Saúde Mental , Pessoa de Meia-Idade , Projetos Piloto , Grupos de Autoajuda , Comportamento Sexual/psicologia
10.
Artigo em Inglês | MEDLINE | ID: mdl-31102114

RESUMO

PURPOSE: Pulmonary vein isolation (PVI) by cryoballoon ablation (CBA) has emerged as a commonly used technique for the treatment of atrial fibrillation. We sought to explore the incidence, risk factors for, and characterization of post-CBA-PVI atrial flutter. METHODS: We analyzed a prospective registry of patients who underwent CBA-PVI at a single institution. We included patients with more than 3 months of follow-up data and excluded those with a history of cavotricuspid isthmus (CTI) ablation. Locations of post-CBA-PVI atrial flutters were determined by analysis of intracardiac electrograms and electroanatomic maps. RESULTS: There were 556 patients included in the analysis. The mean age was 61.0 ± 10.6 years, 67.4% were male, the number of failed anti-arrhythmic medication trials was 1.2 ± 0.8, and the duration of atrial fibrillation pre-CBA was 54.3 ± 69.1 months. The 28-mm second-generation cryoballoon was used almost exclusively. Over a median follow-up time of 22.7 ± 17.9 months, 25 (4.5%) patients developed post-CBA-PVI atrial flutter after the 3-month blanking period. Of those 25 patients, 15 (60%) underwent subsequent ablation to eliminate the atrial flutter circuit, with 60% being CTI-dependent and the remainder left-sided (p value not significant). Risk factors for the development of atrial flutter included NYHA class ≥ 2 (OR 5.02, p < 0.001), presence of baseline bundle branch block (OR 4.33, p = 0.006), and left ventricular ejection fraction < 50% (OR 3.36, p = 0.007). CONCLUSIONS: The rate of post-CBA-PVI atrial flutter is low after the blanking period even with medium-term follow-up. The origin of atrial flutter is equally divided between the right and left atria.

11.
Pacing Clin Electrophysiol ; 42(6): 694-704, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30912155

RESUMO

BACKGROUND: While several studies have evaluated predictors for atrial fibrillation (AF) recurrence following catheter ablation, there are limited data specific to cryoballoon ablation (CBA). METHODS: We analyzed a prospective registry of patients at a single institution who underwent CBA. Recurrence of AF (RAF) was defined as recurrence of AF by 12-month follow-up, excluding the 3-month blanking period. Univariate analysis was performed to evaluate predictors of RAF. Receiver operating characteristic analysis was used to compare and evaluate the performance of various risk scores for discriminating risk of RAF. RESULTS: There were 542 patients included in the analysis with mean age 61.3 ± 10.6 years, 67.9% male, and 51.6% paroxysmal AF (PAF). Overall, only left atrial diameter (LAD) > 40 mm and ERAF (early recurrence of AF within 0-3 month blanking period) were significant predictors of RAF. In the PAF specific subgroup, LAD > 40 mm, AF duration > 12 months, prior stroke or transient ischemic attack, ERAF, and having previously failed an antiarrhythmic drug were significant predictors of RAF. In persistent AF (PeAF) subgroup, obstructive sleep apnea (OSA) and ERAF were significant predictors of RAF. Out of clinical risk scores tested, BASEAF2 had the highest performance with area under the curve of 0.646 (95% confidence interval [0.548, 0.708]; P < .01). CONCLUSIONS: In this single-center retrospective study of CBA, we found only LAD > 40 mm and ERAF to be predictors of RAF. We identified OSA as a potential targetable risk factor in PeAF patients undergoing CBA. Out of risk scores tested for discriminating risk of RAF, BASEAF2 had the best performance.

12.
Pacing Clin Electrophysiol ; 42(2): 146-152, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30548869

RESUMO

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is increasingly used to treat severe aortic stenosis. A frequent complication of TAVR is high-grade or complete atrioventricular (AV) block requiring a permanent pacemaker (PPM). There are little data on the long-term dependency on pacing after TAVR. The objective of this study was to determine the proportion of patients receiving a PPM for high-grade or complete AV block after TAVR who remain dependent on the PPM in follow-up and to determine any risk factors for, particularly the effect of postballoon dilation (PBD) on, pacemaker dependency. METHODS: Of 594 consecutive patients without prior PPM undergoing TAVR (81.9% balloon-expandable, 18.1% self-expandable valve), 67 (13.1%) received a PPM after TAVR. PPM dependency was defined as AV block with a ventricular escape rate of ≤ 40 beats/min. Patient and procedural characteristics were examined according to PPM dependency status. RESULTS: Of the 67 patients who received a PPM within 10 days after TAVR, 27/67 (40.3%) were dependent at first follow-up and only 9/41 (21.9%) at 1 year. PPM dependency was more common after a self-expanding valve (76.9% vs 31.5%, P < 0.01), in those who underwent PBD (66.7% vs 24.4%, P < 0.01), and in patients in persistent complete AV block at PPM implantation (62.5% vs 7.4%, P < 0.01). CONCLUSIONS: Fewer than half of patients who receive a new PPM following TAVR are pacemaker dependent at early follow-up (< 30 days). The use of self-expanding valves and PBD are associated with a markedly increased risk of PPM dependency.


Assuntos
Bloqueio Atrioventricular/etiologia , Bloqueio Atrioventricular/terapia , Marca-Passo Artificial , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Substituição da Valva Aórtica Transcateter/efeitos adversos , Idoso de 80 Anos ou mais , Bloqueio Atrioventricular/fisiopatologia , Feminino , Sistema de Condução Cardíaco , Humanos , Masculino , Marca-Passo Artificial/efeitos adversos , Complicações Pós-Operatórias/fisiopatologia , Recuperação de Função Fisiológica , Estudos Retrospectivos , Medição de Risco , Fatores de Risco
13.
Am J Cardiol ; 122(7): 1175-1178, 2018 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-30072132

RESUMO

The efficacy of novel oral anticoagulants (NOACs) in severely obese patients is uncertain as volume of distribution is related to weight, and few such patients were enrolled in the pivotal trials. As the month after direct-current cardioversion (DCCV) for atrial fibrillation and atrial flutter is a high-risk period for stroke, we sought to evaluate the safety of performing DCCV in obese patients on NOAC. All patients who underwent DCCV after ≥3 weeks of NOAC or therapeutic warfarin treatment without a previous transesophageal echocardiogram over a 3-year period at a single center were included. Obesity groups were defined as normal (body mass index [BMI] < 25), overweight (BMI 25 to <30), class 1 obesity (BMI 30 to <35), class 2 obesity (BMI 35 to <40), and class 3 or severe obesity (BMI ≥ 40). The primary end point was stroke at 30days. Of 761 patients, 73 were severely obese, 78 class 2 obese, 197 class 1 obese, 254 overweight, and 159 in the normal weight group. Average age 66.4 ± 10.3years and 32.5% women. Mean CHA2DS2-VASc score was 2.6 ± 1.6, and 78.9% were on NOACs with no differences in groups. There were no strokes in the severely obese group, and 1 each in class 2 obesity and normal weight (p = 0.3). In conclusion, there was a low rate of stroke in all weight classes after DCCV in patients taking NOACs and warfarin. NOAC use in severely obese patients who underwent DCCV appears safe even in the absence of transesophageal echocardiogram.


Assuntos
Anticoagulantes/administração & dosagem , Fibrilação Atrial/terapia , Flutter Atrial/terapia , Cardioversão Elétrica , Obesidade/complicações , Acidente Vascular Cerebral/prevenção & controle , Administração Oral , Idoso , Antiarrítmicos/administração & dosagem , Fibrilação Atrial/diagnóstico por imagem , Flutter Atrial/diagnóstico por imagem , Ecocardiografia Transesofagiana , Feminino , Humanos , Masculino , Estudos Retrospectivos
16.
Eur J Heart Fail ; 20(4): 630-641, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29082676

RESUMO

Acute heart failure (HF) is a global pandemic with more than one million admissions to hospital annually in the US and millions more worldwide. Post-discharge mortality and readmission rates remain unchanged and unacceptably high. Although recent drug development programmes have failed to deliver novel therapies capable of reducing cardiovascular morbidity and mortality in patients hospitalized for worsening chronic HF, hospitalized HF registries and clinical trial databases have generated a wealth of information improving our collective understanding of the HF syndrome. This review will summarize key insights from clinical trials in acute HF and hospitalized HF registries over the last several decades, focusing on improving the management of patients with HF and reduced ejection fraction.


Assuntos
Insuficiência Cardíaca/epidemiologia , Hospitalização/tendências , Sistema de Registros , Doença Aguda , Saúde Global , Mortalidade Hospitalar/tendências , Humanos , Morbidade/tendências , Prognóstico , Taxa de Sobrevida/tendências
17.
J Atr Fibrillation ; 9(5): 1510, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29250268

RESUMO

Background: Adenosine can unmask dormant conduction during pulmonary vein isolation (PVI) for atrial fibrillation (AF). Studies of adenosine use in radiofrequency PVI show high reconnection rates and conflicting results for long-term success, however there is limited data with cryoballoon ablation (CBA). Methods: A prospectively maintained database of patients undergoing first CBA at a single institution was analyzed. Adenosine use was at the discretion of the primary operator. Additional freezes were delivered for reconnected veins until dormant conduction was eliminated. The primary endpoint, time to AF recurrence defined as any episode < 30 seconds after a 3-month blanking period, was assessed by Kaplan-Meier analysis. Results: From 2011 to 2015, 406 patients underwent CBA, 361 of whom had > 3 months follow-up. The mean age was 61.7 years, 69% were male, and the prevalence of paroxysmal AF was 79% with no significant difference between those that did and did not receive adenosine (77% vs 86%, respectively, p = 0.23). Adenosine testing was performed in 78 patients (21.6%) with a mean dose of 10.6 mg/vein. Of the 306 veins evaluated, 17 (6%) demonstrated dormant conduction. Over a median 14.4 months follow-up, there was no significant difference in freedom from AF with adenosine use (p= 0.86). Conclusions: Dormant conduction with adenosine is uncommon following CBA and its use does not improve long-term success rates.

18.
Int J Health Policy Manag ; 6(8): 477-479, 2017 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-28812848

RESUMO

In response to this insightful editorial, we wish to provide commentary that seeks to highlight recent successes and illuminate the often unspoken hurdles at the intersections of culture, politics, and taboo. We focus on sexual transmission and draw examples from Lebanon, where the pursuit of data in quality and quantity is teaching us lessons about the way forward and where we are experiencing many of the challenges referenced in the editorial such as discrepancies between national statistics and rates derived via research as well as the impact of protracted political conflict and displacement. Two important points were raised in the editorial about HIV in Middle East and North Africa (MENA) that we would like to expand further: (1) The epidemic is largely driven by drug-related and sexual behavior among key populations; and (2) Several key populations continue to be criminalized and excluded from surveillance programs.


Assuntos
Infecções por HIV , Minorias Sexuais e de Gênero , África do Norte , HIV , Humanos , Líbano , Comportamento Sexual
19.
Clin Cardiol ; 40(11): 1044-1048, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28800149

RESUMO

BACKGROUND: Atrial fibrillation (AF) burden and duration are predictors of thromboembolic events. The random nature of these measures may affect clinical decision making. The objective of this study was to determine temporal changes in AF burden as detected by continuous monitoring. HYPOTHESIS: AF burden changes over time when detected by continuous monitoring. METHODS: A post hoc analysis of patients enrolled in the TRENDS (A Prospective Study of the Clinical Significance of Atrial Arrhythmias Detected by Implanted Device Diagnostics) study with ≥1 stroke risk factor(s) who were implanted with a dual-chamber cardiac rhythm management device (CRMD) and had AF burden data available for ≥2 years was performed. AF burden was defined as no AF, low AF (<5.5 hours on any given day), or high AF burden (≥5.5 hours in a day), and was first assessed over the initial 30 days following enrollment and then reassessed at 6-month intervals for 2 years. RESULTS: Among 394 patients included, the average age was 70.2 ± 10.9 years, 71% were male, and mean CHA2 DS2- VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or TIA, vascular disease, age 65-74 years, sex category) score was 3.7 ± 1.6. In the 30-day baseline period, 75.1% of patients had no AF, 11.2% had low AF, and 13.7% had high AF. Over the subsequent 2 years, 40.0% of patients initially classified as no AF or low AF experienced periods with high AF, whereas 59.3% of patients initially classified as high AF experienced ≥6 consecutive months with no AF or low AF. Advanced age was the sole predictor of AF progression. CONCLUSIONS: Significant temporal variability in AF burden exists when measured continuously with an implantable CRMD.


Assuntos
Fibrilação Atrial/diagnóstico , Dispositivos de Terapia de Ressincronização Cardíaca , Terapia de Ressincronização Cardíaca , Desfibriladores Implantáveis , Cardioversão Elétrica/instrumentação , Insuficiência Cardíaca/terapia , Frequência Cardíaca , Monitorização Ambulatorial/instrumentação , Telemetria/instrumentação , Potenciais de Ação , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/fisiopatologia , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Fatores de Tempo , Resultado do Tratamento
20.
JACC Clin Electrophysiol ; 3(12): 1447-1452, 2017 12 11.
Artigo em Inglês | MEDLINE | ID: mdl-29759676

RESUMO

OBJECTIVES: This study sought to determine the feasibility, safety, and efficacy of elective electrical cardioversion (CV) for atrial fibrillation (AF) when performed autonomously by a trained advanced practice provider (APP) using a guideline-directed protocol. BACKGROUND: APPs have emerged as an integral part of the cardiovascular team. METHODS: A licensed advanced practice nurse-clinical nurse specialist was trained and obtained credentials to perform CVs. The advanced practice nurse performed 415 CVs autonomously (APP group) in a noninvasive procedure room with an electrophysiologist (EP) immediately available in an adjacent electrophysiology laboratory. The APP performed a history and physical examination, obtained informed consent, reviewed each patient with the supervising EP, and performed the CV. An anesthesiologist administered sedation. Outcomes were compared with 387 CVs performed by an MD when the APP was not available (MD group). Patient satisfaction scores were compared before and after the APP-directed CVs were performed. RESULTS: The proportion of patients discharged in sinus rhythm was the same in the APP group as it was in the MD group (95% vs. 96%, respectively; p = 0.49). There were 4 adverse events in the CVs performed by the APP: 1 transient ischemic attack and 3 occurrences of bradycardia requiring atropine or other medication. There was 1 adverse event in the MD group, which was hypotension requiring vasopressor initiation. Patient satisfaction scores were stable after initiation of APP-driven cardioversions. CONCLUSIONS: With appropriate clinical training, an APP can safely perform CVs autonomously, using a protocol that includes a guideline-directed procedural checklist and physician supervision, with excellent patient satisfaction and outcomes.


Assuntos
Fibrilação Atrial/terapia , Cardioversão Elétrica/efeitos adversos , Guias de Prática Clínica como Assunto/normas , Disfunção Ventricular Esquerda/fisiopatologia , Idoso , Fibrilação Atrial/fisiopatologia , Atropina/administração & dosagem , Atropina/uso terapêutico , Bradicardia/epidemiologia , Bradicardia/etiologia , Cardioversão Elétrica/métodos , Técnicas Eletrofisiológicas Cardíacas/métodos , Estudos de Viabilidade , Feminino , Humanos , Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/etiologia , Masculino , Pessoa de Meia-Idade , Antagonistas Muscarínicos/uso terapêutico , Satisfação do Paciente/estatística & dados numéricos , Estudos Prospectivos , Volume Sistólico/fisiologia , Resultado do Tratamento , Disfunção Ventricular Esquerda/diagnóstico por imagem
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